Healthcare Provider Details

I. General information

NPI: 1235433095
Provider Name (Legal Business Name): STEPHANIE GRELLA M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5360 GENESEE ST
BOWMANSVILLE NY
14026-1044
US

IV. Provider business mailing address

5360 GENESEE ST
BOWMANSVILLE NY
14026-1044
US

V. Phone/Fax

Practice location:
  • Phone: 716-783-3151
  • Fax:
Mailing address:
  • Phone: 716-783-3151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberCERTIFICATION1078548
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: